Abstract
Renal sodium avidity, a hallmark of chronic cardiorenal syndrome (CRS), is characterized by persistent sodium retention despite significant fluid overload. This resistance to natriuresis and diuresis exacerbates volume overload, contributes to hemodynamic instability, and accelerates the decline of cardiac and renal function, presenting a critical challenge in long-term CRS management. Conventional diuretic therapies, while effective during acute decompensations, often fail in chronic settings due to neurohormonal activation, renal tubular adaptations, and diuretic resistance. Innovative approaches targeting sodium regulation, including sodium-glucose cotransporter 2 (SGLT2) inhibitors, glucagon-like peptide-1 receptor (GLP-1R) agonists, and extracorporeal techniques such as hemodialysis (HD) and peritoneal dialysis (PD), offer promising alternatives. HD and PD provide precise sodium and fluid removal, bypassing many limitations of pharmacological therapies, with PD showing particular efficacy in refractory cases by preserving residual renal function and enhancing diuretic responsiveness. This review focuses on strategies to overcome resistance to natriuresis and diuresis in patients with chronic CRS. By exploring the underlying pathophysiology, limitations of current therapies, and the potential of advanced interventions like ultrafiltration (UF) through HD and PD, we propose a multidisciplinary and personalized approach to breaking the pathological cycle of sodium retention and fluid overload, ultimately aiming to improve patient outcomes and quality of life. As the saying goes, "there's always more than one way to skin a cat.
